Is the rating result reliable? A new approach to respond to a medical trainee's concerns about the reliability of Mini-CEX assessment.

PURPOSE: Whether the rating result of mini-clinical evaluation exercise (Mini-CEX) for rating clinical skills is reliable is of a medical trainee's great concerns. The objectives of this study were to analyze the test-retest reliability, interrater reliability and internal consistency reliability of Mini-CEX. METHODS: Three clinical scenarios, each played by a standardized patient and resident, were developed and videotaped. A group of assessors were recruited to rate the resident's clinical skills using Mini-CEX with a nine-point grading scale in each videotaped clinical scenario. Each assessor was required: (1) to watch the videotaped clinical scenarios a sequential order; (2) to rate each medical trainee's clinical skills in each clinical scenario for two rating sessions, and there must be a minimum three-week interval between the first and the second Mini-CEX rating session. RESULTS: A total of 38 assessors participated in this study. This study showed that: (1) an assessor carried out similar rating reuslts under the same clinical performance based on an acceptable test-retest reliability (Pearson's correlation coefficients = 0.24-0.76, P value=<0.01-0.14); (2) assessors gave similar rating results to a medical trainee's clinical performance based on a good interrater reliability (intra-class correlation coefficient = 0.57-0.83, P value=<0.01-0.03); and (3) the items reflected unidimensionally a construct-a medical trainee's clinical skills based on an excellent internal consistency reliability (Cronbach's alpha = 0.92-0.97). CONCLUSION: This study convincingly showed that Mini-CEX is a reliable assessment tool for rating clinical skills, and can be widely used to assess medical trainees' clinical skills.

Correlations of clinical parameters with quality of life in patients with acromegaly: Taiwan Acromegaly Registry.

BACKGROUND/PURPOSE: The objectives of this study were to evaluate the associations between clinical parameters and quality of life (QOL) of patients with acromegaly in Taiwan and to identify the impacts of hormone control, regimens, or co-morbidities on acromegalic patients' daily life. METHODS: From 2013 to 2015, subjects with acromegaly were recruited through five medical centers. Clinical data were recorded. The QOL of enrolled patients were assessed by using Acromegaly Quality of Life Questionnaire (AcroQoL). RESULTS: This study enrolled 272 acromegalic subjects (117 males, 155 females). Remission, defined by normalization of IGF-1, had significant positive association with QOL scores in psychological/appearance (PSY/APP) dimension (ß = 6.760, p = 0.023). Somatostatin analogues therapy had negative associations with total score and score in psychological (PSY) dimension (ß = -4.720, p = 0.046 and ß = -5.388, p = 0.035, respectively). Diabetes mellitus had negative associations with score in PSY dimension and psychological/personal relations (PSY/PER) dimensions (ß = -5.839, p = 0.034 and ß = -7.516, p = 0.013, respectively). Cerebral vascular accident (CVA) had significant negative associations with total score and scores in physical (PHY), PSY, and PSY/PER dimensions (ß = -26.632, p = 0.013; ß = -28.353, p = 0.024; ß = -25.648, p = 0.026; and ß = -34.586, p = 0.006, respectively). All these associations remained significant even after adjusted with sex and age. CONCLUSION: Our analysis suggested that not only hormone control but also therapeutic regimens and presence of co-morbidities might affect QOL of patients with acromegaly in some dimensions.

A registry of acromegaly patients and one year following up in Taiwan.

BACKGROUND/PURPOSE: The objectives of this study were to describe epidemiological data, treatment outcomes, and quality of life (QOL) of patients with acromegaly in Taiwan. METHODS: From 2013 to 2015, subjects with acromegaly were recruited through five medical centers. After enrollment, each patient was kept on observation for 1 year. RESULTS: The analyzed cohort included 272 acromegalic subjects (117 males, 155 females) with a mean age of 51.4 ± 12.9 years. Their mean age at diagnosis was 41.8 ± 12.1 years. About 83.8% patients presented symptoms of facial changes. Galactorrhea was noted at the earliest age of 32.7 ± 9.1 years. The duration between the onset of symptoms/signs and diagnosis was 6.9 ± 8.1 years. Around 70.3% patients harbored a macroadenoma. At enrollment, percentages of patients ever received surgical intervention, radiotherapy, somatostatin analogs, and dopamine agonists were 94.8%, 27.9%, 64%, and 30%, respectively. At the final following-up visit, the random growth hormone (GH), nadir GH after oral glucose tolerance test, and the insulin-like growth factor 1 levels were 2.7 ± 4.9 µg/L, 2.4 ± 6.1 µg/L, and 291.5 ± 162.4 ng/mL, respectively. The remission rate assessed by random GH level (≦2 µg/L) was 63.8%. The mean AcroQoL scores for the total 22 items were 64.0 ± 19.7. About 42.8% patients never sensed or felt discomfort about their changes in appearance. CONCLUSION: This study described the profiles of acromegaly in Taiwan. It is important to enhance early diagnosis and timely commencement of treatment to prevent serious complications of acromegaly.

Gender and age disparity in the initiation of life-supporting treatments: a population-based cohort study.

BACKGROUND: The relationships between age and the life-supporting treatments use, and between gender and the life-supporting treatments use are still controversial. Using extracorporeal membrane oxygenation as an example of life-supporting treatments, the objectives of this study were: (1) to examine the relationship between age and the extracorporeal membrane oxygenation use; (2) to examine the relationship between age and the extracorporeal membrane oxygenation use; and (3) to deliberate the ethical and societal implications of age and gender disparities in the initiation of extracorporeal membrane oxygenation. METHODS: This is a population-based, retrospective cohort study. Taiwan's extracorporeal membrane oxygenation cases from 2000 to 2010 were collected. The annual incidence rate of extracorporeal membrane oxygenation use adjusting for both age and gender distribution for each year from 2000 to 2010 was derived using the population of 2000 as the reference population. The trend of extracorporeal membrane oxygenation use was examined using time-series linear regression analysis. We conducted joinpoint regression for estimating the trend change of extracorporeal membrane oxygenation use. RESULTS: The trends of extracorporeal membrane oxygenation use both for different gender groups, and for different age groups have been significantly increasing over time. Men were more likely to be supported by extracorporeal membrane oxygenation than women. Women's perspectives toward life and death, and women's perception of well-being may be associated with the phenomenon. In addition, the patients at the age of 65 or older were more likely to be supported by extracorporeal membrane oxygenation than those younger than 65. Family autonomy/family-determination, and the Confucian tradition of filial piety and respecting elders may account for this phenomenon. CONCLUSIONS: This study showed gender and age disparities in the initiation of extracorporeal membrane oxygenation use in Taiwan, which may be accounted for by the cultural and societal values in Taiwan. For a healthcare professional who deals with patients'/family members' medical decision-making to initiate life-supporting treatments, he/she should be sensitive not only to the legality, but also the societal and ethical issues involved.

An isodicentric X chromosome with gonadal dysgenesis in a lady without prominent somatic features of Turner's syndrome. A case report.

Isodicentric X chromosomes in general have phenotypes characteristic of the resultant X deletions. Gonadotropin levels in Turner's syndrome (TS) girls are high, but have a normal biphasic pattern. Here, we report a 21-year-old lady with primary amenorrhea. Clinical examination revealed a short neck but no other typical stigmata of Turner's syndrome. The levels of gonadotropin were not raised to post-menopausal levels. A chromosome study showed a 45,X/46,X,idic(X)(q22) karyotype. She was diagnosed as having Turner's syndrome.

The over-optimistic portrayal of life-supporting treatments in newspapers and on the Internet: a cross-sectional study using extra-corporeal membrane oxygenation as an example.

BACKGROUND: Extra-corporeal membrane oxygenation has been introduced to clinical practice for several decades. It is unclear how internet and newspapers portray the use of extra-corporeal membrane oxygenation. This study were: (1) to quantify the coverage of extra-corporeal membrane oxygenation use in newspapers and on the Internet; (2) to describe the characteristics of extra-corporeal membrane oxygenation users presented in newspaper articles and the Internet web pages in comparison with those shown in extra-corporeal membrane oxygenation studies in Taiwan; and (3) to examine the survival rates of extra-corporeal membrane oxygenation users presented in newspaper articles and the Internet web pages in comparison with those in Taiwan and in the Extracorporeal Life Support Registry Report International Summary for January 2014. METHODS: All issues of Taiwan's four major newspapers from 2006 to 2010 were reviewed. In October 2011, a search of Internet web pages was performed based on the subjects of "yeh-ko-mo" (extra-corporeal membrane oxygenation in Traditional Chinese), "ECMO", and "extra-corporeal membrane oxygenation." All the Internet web pages and newspaper articles recounting the use of extra-corporeal membrane oxygenation were reviewed. The information, such as patient characteristic and the status at hospital discharge, was collected. RESULTS: The survival rate of extra-corporeal membrane oxygenation use shown on the Internet (83.97%) was significantly higher than all the survival rates reported in Taiwan's literature (p < .01) and in the Extracorporeal Life Support Registry Report International Summary for January 2014 (p < .01). In addition, the survival rate of extra-corporeal membrane oxygenation use shown in newspapers (61.54%) was significantly higher than the average survival rate (43%) reported in Taiwan's literature, the pediatric average survival rate (51%), and the adult average survival rate (47%) in the Extracorporeal Life Support Registry Report International Summary for January 2014. CONCLUSIONS: Internet and newspapers both showed over-optimistic survival to hospital discharge for patients sustained by extra-corporeal membrane oxygenation. Internet was more likely to provide optimistic information for aggressive life-supporting treatments such as extra-corporeal membrane oxygenation than newspapers as indicated by survival to hospital discharge.

To evaluate the effectiveness of health care ethics consultation based on the goals of health care ethics consultation: a prospective cohort study with randomization.

BACKGROUND: The growing prevalence of health care ethics consultation (HCEC) services in the U.S. has been accompanied by an increase in calls for accountability and quality assurance, and for the debates surrounding why and how HCEC is evaluated. The objective of this study was to evaluate the effectiveness of HCEC as indicated by several novel outcome measurements in East Asian medical encounters. METHODS: Patients with medical uncertainty or conflict regarding value-laden issues, and requests made by the attending physicians or nurses for HCEC from December 1, 2009 to April 30, 2012 were randomly assigned to the usual care group (UC group) and the intervention group (HCEC group). The patients in the HCEC group received HCEC conducted by an individual ethics consultant. Data analysis was based on the intention-to-treat principle. Mann-Whitney test and Chi-squared test were used depending on the scale of measurement. RESULTS: Thirty-three patients (53.23%) were randomly assigned to the HCEC group and 29 patients were randomly assigned to the UC group. Among the 33 patients in the HCEC group, two (6.06%) of them ultimately did not receive a HCEC service. Among the 29 patients in the UC group, four (13.79%) of them received a HCEC service. The survival rate at hospital discharge did not differ between the two groups. Patients in the HCEC group showed significant reductions in the entire ICU stay and entire hospital stay. HCEC significantly facilitated achieving the goal of medical care (p < .01). Furthermore, patients in the HCEC group had a shorter ICU stay and shorter hospital stay after the occurrence of medical uncertainty or conflict regarding value-laden issues than those in the UC group. CONCLUSIONS: Our findings demonstrated that HCEC were associated with reduced consumption of medical resources as indicated by shorter entire ICU stay, entire hospital stay, and shorter ICU and hospital stay after the occurrence of the medical uncertainty or conflict regarding value-laden issues. This study also showed that HCEC facilitated achieving a consensus regarding the goal of medical care, which conforms to the goal of HCEC.

Significant social events and increasing use of life-sustaining treatment: trend analysis using extracorporeal membrane oxygenation as an example.

BACKGROUND: Most studies have examined the outcomes of patients supported by extracorporeal membrane oxygenation as a life-sustaining treatment. It is unclear whether significant social events are associated with the use of life-sustaining treatment. This study aimed to compare the trend of extracorporeal membrane oxygenation use in Taiwan with that in the world, and to examine the influence of significant social events on the trend of extracorporeal membrane oxygenation use in Taiwan. METHODS: Taiwan's extracorporeal membrane oxygenation uses from 2000 to 2009 were collected from National Health Insurance Research Dataset. The number of the worldwide extracorporeal membrane oxygenation cases was mainly estimated using Extracorporeal Life Support Registry Report International Summary July 2012. The trend of Taiwan's crude annual incidence rate of extracorporeal membrane oxygenation use was compared with that of the rest of the world. Each trend of extracorporeal membrane oxygenation use was examined using joinpoint regression. RESULTS: The measurement was the crude annual incidence rate of extracorporeal membrane oxygenation use. Each of the Taiwan's crude annual incidence rates was much higher than the worldwide one in the same year. Both the trends of Taiwan's and worldwide crude annual incidence rates have significantly increased since 2000. Joinpoint regression selected the model of the Taiwan's trend with one joinpoint in 2006 as the best-fitted model, implying that the significant social events in 2006 were significantly associated with the trend change of extracorporeal membrane oxygenation use following 2006. In addition, significantly social events highlighted by the media are more likely to be associated with the increase of extracorporeal membrane oxygenation use than being fully covered by National Health Insurance. CONCLUSIONS: Significant social events, such as a well-known person's successful extracorporeal membrane oxygenation use highlighted by the mass media, are associated with the use of life-sustaining treatment such as extracorporeal membrane oxygenation.

Cushing's Syndrome is Associated with a Higher Risk of Cancer - A Nationwide Cohort Study.

CONTEXT: Patients with Cushing's syndrome (CS) have higher risk of obesity and diabetes, which are important risk factors of cancers. However, if patients with CS have a higher incidence of cancer remains unknown. OBJECTIVE: To investigate if endogenous CS is associated with increased cancer incidence. DESIGN: A nationwide cohort study. SETTING: Analysis of the data retrieved from Taiwan's National Health Insurance program in 2006-2017. PARTICIPANTS: Between 2006-2017, 1278 patients with newly diagnosed endogenous CS were identified. Among them, 1246 patients without a history of malignancy were enrolled in this study. EXPOSURES: Endogenous CS. MAIN OUTCOMES MEASURES: The age- and sex-standardized incidence rate of all-cause cancer and age-sex-calendar year standardized incidence ratio (SIR) of cancer in association with endogenous CS. RESULTS: The age- and sex-standardized incidences of CS decreased from 4.84 to 3.77 per million person-years between 2006-2017. The age at diagnosis of CS was 45.3 ± 14.8 years, and 80.0% of the patients were female. Cushing's disease and adrenal CS accounted for 35.4% and 64.6% of patients with CS, respectively. The incidence rate of cancer in patients with CS was 7.77 (95% Confidence Interval [CI] = 5.84-10.14) per 1000 person-years, with an SIR of 2.08 (95% CI = 1.54-2.75). The three most common cancer types were liver (27.7%), kidney (16.7%), and lung (13.0%). CONCLUSIONS: Patients with endogenous CS have a higher incidence of cancer.

Thyrotropin-secreting pituitary tumor presenting with congestive heart failure and good response to dopaminergic agonist cabergoline.

Hyperthyroidism is an important inducing factor in patients with atrial fibrillation, and may trigger heart failure. Thyrotropin (thyroid stimulating hormone, TSH)-secreting pituitary tumors are rare causes of hyperthyroidism. Here, we report a 66-year-old man with a pituitary TSH-secreting tumor who presented with hyperthyroidism and congestive heart failure. Endonasal trans-sphenoidal pituitary adenomectomy was performed. After the operation, the symptoms of hyperthyroidism and congestive heart failure were relieved, associated with normalization of thyroid function tests. Unfortunately, hand tremor and progressively elevated free T4 and TSH concentrations recurred 5 months after surgery. A dopaminergic agonist, cabergoline was administered and euthyroidism was restored for at least 11 months.

Menstrual effects among women exposed to polychlorinated biphenyls and dibenzofurans.

BACKGROUND: Polychlorinated biphenyls (PCBs), dibenzofurans (PCDFs), and dibenzo-dioxins (PCDDs) may affect the female reproductive system in humans. A mass poisoning occurred in Taiwan due to PCBs/PCDFs-contaminated cooking oil, and was called the Yucheng (oil-disease in Chinese). We aimed to determine whether Yucheng women were affected in their menstruation. METHODS: After the event, we followed the exposed individuals and an age-matched neighborhood reference group. Menstrual cycle characteristics and age at menarche were obtained by a telephone interview. We used multiple linear and logistic regression to examine the association between PCBs/PCDFs and menstrual cycle characteristics, after adjusting for confounding factors. RESULTS: Totally 445 women responded satisfactorily and were included in the analyses of menstrual characteristics. Menstrual cycle irregularity and dysmenorrheal did not differ between Yucheng and referents. Yucheng women's menstrual cycles were 0.5 (95% CI: 0.0-0.5; p=0.03) days shorter than those of the referents. The Yucheng women with skin lesions caused by PCBs/PCDFs were more prominently affected, with the cycles 1.2 days shorter than the referents. Yucheng women exposed to PCBs/PCDFs at the premenacheal period had reduced cycle length (-0.7 day, 95% CI: -1.4 to 0.0; p=0.04) and longer days of menstrual flow (0.5 day, 95% CI: 0.0-1.0; p=0.04). Among those women who were exposed at an age of 5-9 years, menarche started slightly earlier with borderline significance. CONCLUSIONS: Shorter menstrual cycle length and a longer duration of bleeding in each cycle were found among women previously exposed to PCBs/PCDFs. These effects were more obviously observed among those exposed at premenarcheal ages.

Asymptomatic chronic hepatitis B virus infection does not increase the risk of diabetes mellitus: a ten-year observation.

BACKGROUND AND AIM: Chronic hepatitis C virus infection has been known to increase the risk of diabetes. Whether this association holds true for chronic hepatitis B virus (HBV) infection remains unclear. We thus conducted this study to investigate the influence of asymptomatic chronic HBV infection on the incidence of diabetes in a longitudinal cohort. METHODS: A total of 1233 adults who received health examinations in 1997-1998 and in 2000-2001 were enrolled. Among them, 483 subjects who received a third health examination in 2006-2008 were further sampled. The prevalence and incidence of diabetes between asymptomatic HBV carriers and non-HBV controls were compared using the chi(2)-test and logistic regression. RESULTS: In 1997-1998, the prevalence rates of diabetes (9.49 and 12.0%) and glucose intolerance (28.5 and 25.4%) in HBV carriers and non-HBV controls were comparable (P > 0.05). There was no significant correlation between asymptomatic HBV infection and the presence of diabetes in subjects examined in 1997-1998, 2000-2001, or 2006-2008 when adjusted for age, gender, and body mass index (P > 0.05). In 296 non-diabetic subjects during 1997-1998, the ten-year incidence of diabetes/glucose intolerance was similar between HBV carriers and non-HBV controls (40.0 and 38.7%, P > 0.05). Moreover, no significant correlation was found between asymptomatic HBV infection and the incidence of diabetes/glucose intolerance in 2006-2008 (P = 0.775). CONCLUSIONS: Compared to non-HBV controls, subjects with asymptomatic chronic HBV infection do not have an increased risk of diabetes, and thus HBV itself is not pro-diabetic.

Employer or Employee: Who is More Likely to Suffer From Burnout?

OBJECTIVE: The aims of this study were to examine burnout among full-time workers and to investigate the effect of employment status on burnout. METHODS: The data of this cross-sectional study were derived from the 2015 Taiwan Social Change Survey. Burnout was measured by the Copenhagen Burnout Inventory's four core items. Employment status was categorized into employer and employee. Multivariate linear regression models were used to assess the associations between employment status and burnout. RESULTS: Among 1007 full-time workers, 21.65% were employers and 78.35% were employees. The multivariate linear regression model indicated that after adjusting for all possible risk factors, being an employer (b = 3.95, 95% CI: 0.40 to 7.50) was associated with an increased risk of burnout among full-time workers. CONCLUSIONS: Employment status was a significant factor of burnout among workers.

Low dose HIV-1 Tat improves the defective nuclear factor (NF)-kappaB activity of dendritic cells from persons with spinal cord injury.

Deficits of immune function may be involved in the infections associated with spinal cord injury (SCI). Previous report showed that the impaired maturation potential of dendritic cells (DCs) contributes to immune defect in persons with SCI, especially in those with tetraplegia. To evaluate the roles of cell signaling in the impaired maturation potential of DCs, we assessed the phenotypic and functional maturation potential of DCs in 20 subjects with trauma-induced stable SCI and their neurologically intact healthy control in the presence of DC stimulators, including HIV-1 Tat protein (Tat). Our results showed the tetraplegic subjects had an impaired maturation potential of DCs. The impairment could be attributed to insufficient nuclear factor (NF)-kappaB activity. The maturation potentials and NF-kappaB activity of DCs in response to stimulators could be improved by pretreatment with Tat, although Tat did not increase DC maturation. The improvement by Tat pretreatment was inhibited by a specific NF-kappaB blocker. We concluded that HIV-1 Tat could improve the maturation potentials of DCs from tetraplegic subjects, through Tat-induced enhancement of NF-kappaB activity. These data suggest a potential therapeutic role of HIV-1 Tat in improving immune function in tetraplegic persons.

Physical distress, emotional status, and quality of life in patients with nasopharyngeal cancer complicated by post-radiotherapy endocrinopathy.

PURPOSE: To explore factors affecting quality of life (QOL) among patients with nasopharyngeal cancer (NPC) complicated by post-radiotherapy endocrinopathy. METHODS AND MATERIALS: This cross-sectional study was conducted in a tertiary medical center and involved a total of 43 post-radiotherapy, recurrence-free NPC patients with endocrinopathy. They performed self-assessment of their emotional status using the Beck Anxiety Inventory and Beck Depression Inventory-II, and their QoL with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) questionnaire and the H&N35 cancer module. RESULTS: Emotional and cognitive functioning of EORTC QLQ-C30 were the most affected. Fatigue, insomnia, and pain were the main concerns. Of the patients, 22 (51.2%) had anxiety and 19 (44.2%) had depression. Both depression and anxiety were negatively correlated with functional scales and global QoL but positively correlated with symptom scales. Multiple linear regression analysis revealed that physical distress symptoms of QLQ-C30 and physical functioning were the significant predictors of global QoL. Emotional and social functioning could predict depression, whereas emotional and physical functioning were significant predictors of anxiety. CONCLUSIONS: NPC patients with post-radiotherapy endocrinopathy exhibit impaired cognitive function and negative emotions. Symptoms of physical distress play an important role in QoL perception. Measurement of EORTC QLQ-C30 can be a useful instrument for the early detection of patients' impaired cognitive function and psychological morbidity. The high psychological distress related to the endocrine disturbances or the impact of NPC itself needs further study.

Circulating levels of markers of inflammation and endothelial activation are increased in men with chronic spinal cord injury.

BACKGROUND/PURPOSE: Accelerated atherogenesis is often seen in individuals with chronic spinal cord injury (SCI). However, the mechanisms contributing to this phenomenon remain unclear. This study aimed to evaluate whether SCI per se is associated with a low-grade chronic inflammatory state and endothelial activation, both of which are well-documented prerequisites for atherogenesis. METHODS: Serum levels of markers of inflammation (C-reactive protein [CRP], interleukin-6, and soluble CD40 ligand) and endothelial activation (endothelin-1, soluble intercellular adhesion molecule-1, and soluble vascular cell adhesion molecule-1 [sVCAM-1]) were measured in SCI patients with CRP levels < 10 mg/L and with no evidence of active infection. Sixty-two men with traumatic neurologically complete SCI (20 tetraplegics and 42 paraplegics) and 29 age-matched male controls were enrolled. RESULTS: Compared with able-bodied controls, subjects with SCI had a significantly lower body mass index (BMI) (-7%) and significantly lower serum levels of albumin (-10%), creatinine (-20%), low-density lipoprotein cholesterol (-10%), and high-density lipoprotein (HDL) cholesterol (-25%), and showed a trend toward higher fasting insulin levels. Irrespective of injury level and duration, subjects with SCI had significantly higher serum levels, compared to able-bodied controls, of CRP (mean, 4.0 +/- 2.7 mg/L vs. 1.4 +/- 1.1 mg/L), interleukin-6 (median, 2.5 pg/mL vs. 0.4 pg/mL; range, 1.5-3.6 pg/mL vs. 0.2-0.5 pg/mL), endothelin-1 (mean, 1.3 +/- 0.4 pg/mL vs. 0.9 +/- 0.3 pg/mL), and sVCAM-1 (mean, 1170 +/- 318 ng/mL vs. 542 +/- 318 ng/mL). The serum levels of all four factors correlated negatively with levels of serum albumin, creatinine and HDL cholesterol, but not with BMI or fasting insulin levels. In multivariate analyses, SCI was the only factor that was independently associated with increased serum levels of CRP, interleukin-6, endothelin-1 and sVCAM-1 after adjustment for confounding factors such as serum albumin and creatinine levels and parameters of dyslipidemia and insulin resistance. CONCLUSION: In this study, we have, for the first time, demonstrated that SCI per se is associated with a low-grade chronic inflammatory state and endothelial activation, which may partly explain the increased atherogenic risk in patients with long-standing SCI.

Students' evaluation on a two-stage anatomy curriculum.

This study evaluated students' perspectives of the two-stage anatomy course, which is designed to retain the time-honored tradition of cadaver dissection and to include innovative components into anatomy education. A total of 94 sixth-year medical students completed a questionnaire survey at the end of the second stage anatomy course. The results showed that more than half of the students were satisfied with the two-stage anatomy course. Students found that cadaver dissection was most helpful in learning anatomy. The two-stage anatomy course can enhance understanding and memory of anatomical knowledge. However, students disagreed on whether or not the two-stage course can reduce the burden of learning or that the parallel study of anatomy and the 'Life and Death' course could change their attitude toward death more effectively. National Licensing Examination revealed no obvious change after the implementation of the new anatomy course. Traditional and innovative components in anatomy curriculum could coexist in harmony. We provided an alternative for those who wanted to retain cadaver dissection in a reformed curriculum. Further study is needed to evaluate the adequacy of anatomy knowledge and student performance in the long run.

Hypopituitarism: a sequela of severe hypoxic encephalopathy.

BACKGROUND/PURPOSE: Central diabetes insipidus (DI) is an established phenomenon after hypoxic encephalopathy or brain death, but hypopituitarism is seldom described. This study investigated the characteristics of 11 patients with DI and hypopituitarism which developed after severe hypoxic encephalopathy. METHODS: The medical records of patients with DI and hypopituitarism after severe hypoxic encephalopathy from 1997 to 2002 were retrospectively reviewed. Eleven patients with DI and hypopituitarism after severe hypoxic episodes were included. Demographic data, primary diagnosis, the time of onset of DI, the time of diagnosis of hypopituitarism, the presence of symptoms of hypopituitarism, and outcome of these patients were analyzed. RESULTS: Eleven patients comprising nine females and two males aged 47.4 +/- 19.3 years (range, 24-74 years) were included. The mean interval from the precipitating event to the onset of DI was 60 +/- 46 hours (range, 11-131 hours). The mean interval from the precipitating event to the diagnosis of hypopituitarism was 423 +/- 182 hours (range, 132-672 hours). The average duration of hospitalization was 63 +/- 35 days (range, 9-113 days). The overall mortality rate during hospitalization was 45%. Four patients died of sepsis and one died of heart failure due to acute myocardial infarction. CONCLUSION: The development of DI after severe hypoxic encephalopathy is a sign of severe brain damage. It usually ensues immediately or days after loss of brain stem reflexes. Hypopituitarism developed several weeks later than DI in these patients. Recognition and treatment of these deficiencies may prevent organ dysfunction.

Follicular thyroid carcinoma with NRAS Q61K and GNAS R201H mutations that had a good (131)I treatment response.

UNLABELLED: We report a case of follicular thyroid carcinoma with concomitant NRAS p.Q61K and GNAS p.R201H mutations, which manifested as a 13.5 cm thyroid mass with lung, humerus and T9 spine metastases, and exhibited good response to radioactive iodine treatment. LEARNING POINTS: GNAS p.R201H somatic mutation is an activating or gain-of-function mutation resulting in constitutively activated Gs-alpha protein and downstream cAMP cascade, independent of TSH signaling, causing autonomously functioning thyroid nodules. NRAS p.Q61K mutations with GNAS p.R201H mutations are known for a good radioactive iodine treatment response.Further exploration of the GNAS-activating pathway may provide therapeutic insights into the treatment of metastatic follicular carcinoma.

Serum dehydroepiandrosterone sulfate concentration is lower in women with primary aldosteronism.

OBJECTIVE: The objective of this article is to measure serum dehydroepiandrosterone sulfate (DHEA-S) concentration in both genders with primary aldosteronism (PA). MATERIALS AND METHODS: The study enrolled 78 subjects with normal controls, 46 subjects with essential hypertension and 85 subjects with PA from October 2007 to June 2011. Subjects with PA were divided into three subtype groups: aldosterone-producing adenoma (APA), bilateral idiopathic hyperplasia (IHA) and PA with negative imaging findings. RESULTS: Women with PA (n = 49) had lower serum DHEA-S levels compared with normal controls and subjects with essential hypertension (p < 0.01). In subtype analysis, only female APAs had lower serum DHEA-S levels (p < 0.01 compared with normal controls, p < 0.01 compared with subjects with essential hypertension). In APA, a significant correlation between tumor size and serum DHEA-S was found in women (p < 0.01). CONCLUSION: Our data suggested that serum DHEA-S levels are lower in women with PA. In subtype groups, only women with APA had lower serum DHEA-S. There was no significant difference between subjects with bilateral essential hyperplasia, PA with negative imaging findings, normal controls and subjects with essential hypertension in both genders. The serum DHEA-S level is negatively correlated with the size of APA.